OH&S Discomfort Survey

This survey was developed by the CUPE Local 3500 Executive Board to gather feedback from our members regarding workplace discomfort with the goal of improving our working conditions in the district. In order to look for ways of addressing the issues, we need to know how our members are feeling. Please, be advised that this survey is strictly confidential and will only be viewed and reviewed by the CUPE Local 3500 Executive Board.

This survey will take approximately 20 minutes (or longer if you want to share more details)
Any fields with an asterix (*) require to be filled in in order to submit the form. Most questions are optional, but in order to properly gather enough information, we ask that you fill out as many fields as possible.

    Name*

    Email*

    1. About Yourself

      2. Job Title*

      Location*

      Shift*

      Height

      Dominant Hand

      Gender

    2. More Details

    1. How long have you worked in your current position?*

    2. How often are you mentally exhausted after work?*

    3. How often are you physically exhausted after work?*

    4. Have you ever had any pain or discomfort during the last year that you believe is related to your work?*

    5. Areas of Pain

      6. For each body part listed below, please indicate how often you experience pain (never, occasionally, often or always). Then indicate on a scale of 0-10 (0 being no pain and 10 being severe pain), how much pain you experience for each body part. Remember, pain includes aches, stiffness, numbness, tingling or burning sensations.

    6. Neck
      Rate your physical discomfort using the scale below:

      (0 - No Discomfort, 10 - Worst Discomfort Imaginable)

      Tasks that usually cause discomfort

    7. Left Shoulder
      Rate your physical discomfort using the scale below:

      (0 - No Discomfort, 10 - Worst Discomfort Imaginable)

      Tasks that usually cause discomfort

    8. Right Shoulder
      Rate your physical discomfort using the scale below:

      (0 - No Discomfort, 10 - Worst Discomfort Imaginable)

      Tasks that usually cause discomfort

    9. Left Elbow
      Rate your physical discomfort using the scale below:

      (0 - No Discomfort, 10 - Worst Discomfort Imaginable)

      Tasks that usually cause discomfort

    10. Right Elbow
      Rate your physical discomfort using the scale below:

      (0 - No Discomfort, 10 - Worst Discomfort Imaginable)

      Tasks that usually cause discomfort

    11. Left Wrist/Hand
      Rate your physical discomfort using the scale below:

      (0 - No Discomfort, 10 - Worst Discomfort Imaginable)

      Tasks that usually cause discomfort

    12. Right Wrist/Hand
      Rate your physical discomfort using the scale below:

      (0 - No Discomfort, 10 - Worst Discomfort Imaginable)

      Tasks that usually cause discomfort

    13. Back
      Rate your physical discomfort using the scale below:

      (0 - No Discomfort, 10 - Worst Discomfort Imaginable)

      Tasks that usually cause discomfort

    14. Left Knee
      Rate your physical discomfort using the scale below:

      (0 - No Discomfort, 10 - Worst Discomfort Imaginable)

      Tasks that usually cause discomfort

    15. Right Knee
      Rate your physical discomfort using the scale below:

      (0 - No Discomfort, 10 - Worst Discomfort Imaginable)

      Tasks that usually cause discomfort

    16. Legs
      Rate your physical discomfort using the scale below:

      (0 - No Discomfort, 10 - Worst Discomfort Imaginable)

      Tasks that usually cause discomfort

    17. Additional Comments

    18. Do you have any suggestions to improve your job tasks or additional comments?

      19. [recaptcha]